Authorization for
Electronic Funds Transfer
and Acceptance of Member Obligations.

To
complete your membership registration:Print out this form.
Complete and sign it.
Then fax it to us along with a copy of your voided check and a copy of your current
license. Our fax number is (888) 582-7026.

If you are
unable to fax them, notify us by email, and send them to:
ProfessionalCharges.com
1530 E. Chevy Chase Dr., Suite 209
Glendale, CA 91206

Bank Information

Name(s) on Bank
Account:___________________________________

Checking Account
Number: _____________________________

ABA Number:__________________
(The 9 digits on your check to the left of the account number.)

I authorize ProfessionalCharges.com to initiate credit
entries (deposits) and debit entries (withdrawals from), and to
initiate if necessary adjustments for any credit or debit
entries in error to my account indicated above and the
bank depository named above to debit and/or credit the same to
such account. This authorization is to remain in full force and
effect until it is terminated according to the terms of the
Membership Agreement I/we have with ProfessionalCharges.com.

I certify that
all information submitted is and will be true and correct. I understand and agree to the
terms of the Member Agreement, and I am personally guaranteeing
all member obligations set forth in the Member Agreement.